LME/MCO Public Comments

After announcing its intention  to begin the disengagement process, Orange County solicited public comments for a period of 60 days. Below are the comments received.

Public comments received

I am writing to the commissary office to give my opinion on the topic of Cardinal Innovations. I lived here with my special needs daughter for 39 years. It is my opinion that Cardinal Innovations is the most useless entity that I have come across. It is all about them.
It will be a blessing to the community to choose some other company to provide services for our community.

Thank you
Christine and Crystal Hughes

Dear Chair Price:

I am not fully prepared to speak tonight. However, I do want to share a few comments with you before the meeting. Please feel free to share my concerns tonight if you choose.
I have read the Disengagement Plan. Given the gravity of the disengagement decision, I was expecting the Disengagement Plan to have significant details. However, the plan is quite vague.
If the plan is approved tonight, my understanding is that it will be posted tomorrow and the 60 day public comment period begins. Given what I have read, I am not sure what it is that we would comment on other than to state what we have been receiving with Cardinal Innovations and request “no harm” in changing MCOs. I was expecting a specific, detailed disengagement plan of what the individuals receiving services, as well as the providers who serve these individuals, stand to gain and / or lose in moving to a different MCO.
I shared in the November 5, 2020 County Commissioner Meeting that Club Nova had concerns related to funding that we currently receive. We also expressed concerns related to the administrative burden. I would like to request that a more detailed plan be presented for us meaningfully comment on.
Thank you, Chair Price.

Kindest Regards,
Karen Kincaid Dunn, Club Nova

Comment left with Clerk to the Board's office via telephone:

Ms. Perry does not want the county to disengage from Cardinal She is happy with the services she receives and has a care coordinator and better case management. She is on Medicare and Medicaid, and receives and Innovations waiver so she can get care in her home. She is concerned disengagement would negatively impact services for clients and that their care would not be of the same quality.

Ellen Perry

This would be a disservice to the IDD population at this time with the pandemic and the impending tailored plan. It seems I'll thought out to make such a drastic change when members will have an opportunities to choose their MCO anyway.

Michaele Hines

I write this comment on behalf of Freedom House Recovery Center, Inc. (FHRC) in Chapel Hill, NC. As you may know, FHRC has been in Chapel Hill for over 45 years. Throughout that time this agency has seen many changes and reiterations in the way mental health and substance use services are provided to adults and children in Orange County. Yet, without a doubt, working with Cardinal Innovations has provided FHRC with the greatest amount of flexibility and resources to serve the people of Orange County.
From the beginning, Cardinal Innovations has demonstrated a commitment to residents of Orange County as they recognize and respond to the growing needs of adults and children with Mental Health and Substance Use diagnosis.  Cardinal has consistently listened to the leadership of FHRC as we expressed changing needs throughout the community and as we sought their support in addressing those changing needs, including:

  • Early in the Covid-19 pandemic, Cardinal quickly adjusted to support providers who were hard-hit by the closures and shutdown. Their swift action helped stabilize many agencies, including FHRC.
  • Cardinal has investing in substance abuse services for both crisis and non-crisis individuals who are not eligible for IPRS or Medicaid – improving access to care for residents of Orange County.
  • Instituting and enrolling agencies, such as FHRC, as Comprehensive Community Clinics to provide Cardinal’s members greater access to safety net services within their local community.
  • Cardinal Innovations has designated staff as liaisons to help FHRC maintain continuity of care as we connect clients with services in the community.

This list is not comprehensive; however, it provides a snapshot of the many ways the staff at Cardinal Innovations has gone above and beyond to ensure the community we serve receives the care they need.
Through the years Cardinal has experienced challenges at senior leadership levels. However, the upheaval at senior levels has never hampered their commitment to the people we serve. The one constant FHRC has experienced with Cardinal Innovations through the years is their willingness to respond when the community calls. Whether that meant internal changes for them or external changes in the way they respond to the community, the Cardinal team has been willing and ready to do whatever is necessary.

Heather Griffin-Dolciey

Ms. Hammersley,

I am writing to you concerned with the recent efforts by Orange County to disengage from Cardinal Innovations to realign with Alliance Health. I work for OE Enterprises, a service provider contracted with both Cardinal and Alliance. I was born and raised in Orange County. I am the parent of two children with intellectual/developmental disabilities, a person living with behavioral health challenges, and in all transparency, my spouse works for Cardinal. I currently serve on the executive team of the NC Association of People Supporting Employment First (NC APSE) and a Senate appointed member of the NC State Rehabilitation Council.
I have experience working with multiple Managed Care Organizations (MCOs), providing a variety of services including employment and community engagement.  Although all MCOs have a required base service, I find service levels and access vary between MCOs. Based on 10+ years of experience working with managed care, I have grave concerns with the prospect of disengaging from Cardinal Innovations to realign with Alliance Health.
Over the past 25+ years I have witnessed, first hand, the changes in NC’s behavioral health system and the continuous impact on our most vulnerable citizens. Currently, NC's Medicaid system is preparing to move into managed care in July 2021 and our behavioral health system is on the cusp of transforming into a whole person model in July 2022. Transitioning services to another MCO in the middle of these two already stressful changes is a recipe for disaster.
The level of services people are able to access through each MCO is different. When looking at service authorizations I find that Alliance typically authorizes between two to four hours a month to help someone keep their job. Cardinal takes a more person-centered approach and authorizes services based on individual need. This approach aligns with Governor Cooper's executive order #92 - Employment First.
Some of my experiences with Alliance are in direct opposition of the Employment First Philosophy. I was once told by a manager at Alliance, in regards to a person who was on the Innovations Waiver, "If someone needs staff the entire time they are working then maybe they shouldn't be working." Everyone deserves the option to work.
MCOs are insurance companies. There are some who necessitate higher levels of service than others. A balance of utilization is needed to make managed care work efficiently; some counties have high utilization, others have low utilization. Speaking from what I have witnessed over the past three decades, Orange County has experienced a population growth of people who need higher levels of services. Has there been thought around what will happen to service levels when Orange joins with other high use areas, like Durham, Wake, Johnston, and Cumberland counties?
As the behavioral health system has changed over the years, unfunded provider burden has increased. We continuously do more with less. This is a creation of the system as a whole. There are subtle differences between MCOs that increase burden. One example is a process referred to as "retroactive pay". If a person loses Medicaid coverage, for any reason, the provider does not get paid until Medicaid is reinstated. This can be an easy fix or take months. This is a particular concern with any Innovations Waiver service which is intended to maintain someone's health and safety. Waiver services are intense and encumber large amounts of revenue for providers. By paying Innovations claims regardless of Medicaid status most MCOs demonstrate their understanding of the burden of retroactive payments on providers and the risk it poses to Waiver recipients. Conversely, Alliance Health applies the retroactive pay process across the board to all Medicaid services, including Innovations. My company has experienced multiple month delays in payment for services due to this process, necessitating redirection of administrative resources to resolve payment issues.
Finally, I am concerned that the public has not truly been made aware of this potential change. Website and social media announcements of realignment plans do not reach all of our citizens. The Orange County draft Continuity of Services plan shows that the county intends to alert all members of the plan to realign with Alliance 60 days prior to the effective date. Speaking as a parent and self-advocate, this timeline is not adequate and squelches the voices of those already disenfranchised and who ultimately will be affected most by this change.
Cardinal is not without its faults. I have seen improvements in many areas under new leadership and they are willing to have conversations around what is and is not working. This move will have a negative impact on thousands of self-advocates, their families, and providers. I ask that you reconsider your decision of realignment and urge our Secretary of Health and Human Services to consider everything above and the impact this move will have on the citizens of Orange County with disabilities.
If you have any questions, please do not hesitate to contact me at 919-413-7476.
Thank you,

Tracey Craven

Dear Chair Price, Vice-Chair Bedford, and Commissioners McKee, Dorosin, Greene, Hamilton, and Fowler:

Club Nova is writing to provide public comment related to Orange County’s request to Secretary Cohen to disengage from Cardinal Innovations Healthcare and realign with Alliance Health.
Club Nova is accredited by Clubhouse International as a Clubhouse Model Program. The Clubhouse Model is an evidence-based practice and is one of the most comprehensive, integrated approaches to working with individuals living with serious mental illness in the nation. The Model has strong outcomes, and it is cost effective.
Some of the issues that we face in North Carolina Mental Health are systemic. While each Managed Care Organization (MCO) has flexibilities, barriers exist at the state level. Until some of these barriers are addressed, similar trends of concerns and complaints with MCOs will likely occur across the state.
Regarding Orange County seeking disengagement from Cardinal Innovations Healthcare, we have hoped that resolutions would emerge through Cardinal, NC DHHS, and Orange County that would mitigate the concerns and avert the disruption of disengagement and realignment for recipients of services and their providers. This is especially concerning given that North Carolina is on the cusp of implementing Medicaid Transformation and Tailored Plans. These changes are on the visible horizon while we remain in a pandemic that has lasted beyond one year. We know the pandemic has taken a toll on recipients of services, their families, their providers, our MCO’s, and NC DHHS.
Below are some of the benefits we have experienced in working with Cardinal Innovations Healthcare:

  • Reduction of the administrative burden by setting clinical policy that allows for up to 40 hours of Clubhouse services per week without requiring authorization. This not only reduces the administrative burden, it also significantly reduces the costs associated with authorizations.
     Allocation of significant Non-UCR Funding to cover some of the services provided that otherwise are not reimbursed.
  • Significant allocation of state funding for our members who are not Medicaid eligible. Club Nova provides a significant volume of services that is not reimbursed. Not losing funding for members who are not Medicaid eligible helps mitigate the overall level of other losses. Cardinal pays the same rate of reimbursement for both Medicaid and state. 
  • Funding support to the two group homes in Orange County for adults living with serious mental illness.
  • Stability payments during the COVID 19 Pandemic
  • A case support definition that was implemented early in the pandemic so that needs of recipients of services could be met and providers had a funding stream to meet the needs. 
  • A sizeable allocation for Club Nova toward our expansion project. Our new building will replace the inadequate buildings we have operated in for many years. Our expansion is not solely about a new building. The expansion allows Club Nova to more than double its current capacity thereby meeting the needs of our current and future members as well as the broader community. 
  • Additional payments related to quality of services.
  • An agreement to partner to expand the evidence-based Clubhouse Model in Cardinal’s catchment area.

Historically, during previous leadership, there have been issues with Cardinal. The new leadership at Cardinal has made many positive changes. At least some of the concerns with Cardinal seem to stem from the previous leadership before NC DHHS stepped in to operate Cardinal.
Orange County is part of the regional RTP area. However, in community mental health, we also have Chatham and Person Counties we have been aligned with for many years.
We are concerned about disengagement as the process adds administrative burden not only with realigning but with preparing for Medicaid Transformation and Tailored plans during the same time. Not knowing what MCO we will be aligned with means that we need to be working with both MCO’s on Tailored Plans planning. If realignment is approved, there are costs associated with this type of change. We ask that funds be identified to assist with these added costs to providers.
Over the past two to three years NC DHHS has clearly expressed concerns about disruption that could be caused by disengagements in the midst of transformation. The NC DHHS Joint Communication Bulletin #J282 to the LME-MCOs issued on March 22, 2018 states the following:
Successful transformation to managed care requires coordination across the state and minimizing unnecessary change. As such, each LME/MCO and County must stabilize their healthcare delivery systems. During this period of transition, if the Department were asked to evaluate any disengagement or realignment requests, it would be required to consider the impact on the stability of the healthcare system and would likely find granting such a request to cause negative impact. If Counties have concerns about the services managed and authorized by an LME/MCO, please raise those concerns to the Department (NC DHHS).
In early 2019, Secretary Cohen requested that the North Carolina Association of County Commissioners (NCACC) create a task force to recommend the best path forward with Tailored Plan regions. Orange County submitted a letter to the task force stating a preference to align with Alliance Healthcare. The NCACC submitted to the Secretary their recommendations. On July 2, 2019, the Secretary accepted the core recommendations of the NCACC as follows:
 The seven current LME-MCO regions remain the same leading up to 2021 and through 2025 with two conditions:

  • If the LME-MCO is deemed not viable as it relates to finances or any other condition, then each county may appeal to the NCDHHS Secretary to move to another LME-MCO.
  • Current LME-MCOs should not be prohibited from voluntarily merging with another LME-MCO between 2019-2025. However, a merger should not be mandated.

Questions, Comments, and Due Diligence

Has Orange County conducted any research into the impact of realignment on individuals living with serious mental illness and their services?
What outreach measures have been taken for soliciting input from recipients of services during the public comment period?
What are the short-term and long-term implications of disengagement and realignment?
Is there a guarantee (commitment) that services and funding will not be reduced?
What is the impact on the two group homes in Orange County for individuals living with serious mental illness that Cardinal funds? Will they continue to be funded if realignment is approved?
 If realignment is approved, we request the following commitments and information on how these commitments will be obtained:

  • Up to 40 hours per week of Clubhouse services without requiring authorizations and lifting any other administrative burdens that may exist that are not currently required by Cardinal.
  • At least the same level of non UCR and state funding
  • At least the same psychosocial rehabilitation rate of reimbursement for state funded memberIf any reimbursement rates are higher, that we receive this higher rate of reimbursement.
  • Funding for the two group homes in Orange County for adults living with serious mental illness.
  • The recipients of services will maintain their services and their service providers.
  • Funds for the administrative and other costs associated with disengagement and realignment.
  • Most importantly, if realignment is approved, we need lasting commitments beyond assuring a smooth transition.

Club Nova is happy to work with each MCO. We already work with at least three. We ask that the remainder of the processes weigh all factors before making a final decision. If realignment is the final decision, we ask that a plan be developed to mitigate any potential negative consequences in the disengagement / realignment process.

Thank you for your consideration.


Karen Kincaid Dunn, Executive Director
Club Nova Community, Inc.

Orange County Board of Commissioners:

My name is Jessica Zollinger and I work with children in foster care as they find permanency through adoption. As you can imagine, children in foster care regularly touch the Medicaid system, specifically Cardinal Innovations.
The Medicaid funded mental health system in North Carolina can be challenging to navigate and unfortunately there are not enough mental health placements for children in foster care through Cardinal Innovations. Because of a lack of placements, children live in hospitals because there is not a bed available for them in a therapeutic foster home, group home, or psychiatric facility. Children can have 10, 20, even 30 placements and still not have their mental health symptoms addressed and trauma treated. This is not just the fault of Cardinal Innovations- in fact, all LME/MCOs are sure to have these systemic issues. However, historically in my experience with Cardinal Innovations, there is a lack of urgency and support for families and DSS guardians in locating appropriate placements for children.
I strongly support disengaging from Cardinal Innovations and realigning with Alliance Health. The fact that our neighboring counties also partner with Alliance Health will ensure that children in foster care are able to stay closer to their home community instead of being placed in cities like Charlotte or Asheville.
I do ask that you hold Alliance Health accountable in providing the needed services- children in foster care need local government and citizens to advocate for them.
Thank you for your consideration,

Jessica Zollinger, MSW, LCSWA

As an Orange County resident, a psychiatrist, and a former member of the Cardinal Innovations Board of Directors, I have had ample exposure to North Carolina’s LME/MCO system. In my professional experience, Cardinal Innovations has been one of the most responsive, well organized MCOs I’ve interacted with.  I have witnessed firsthand how Cardinal’s care coordination services have changed the lives of its members, for the better.  On paper, the argument for Orange County to realign with another MCO which manages Medicaid, State, County and other publicly funded behavioral health services in surrounding counties makes sense from an efficiency standpoint. However, I worry the purported gains are illusory and are not worth the potential disruption in services to our community’s most vulnerable population.

Jennifer Richards

I am both a provider of IDD services and brother-in-law to a person with Traumatic Brain Injury and Bipolar Disorder. He experiences severe psychosis when not receiving ongoing supervision and treatment. 

As a provider, I have worked with both Alliance Behavioral Health and with Cardinal Innovations. Our experience with Alliance led us to stop providing services for them. Alliance care coordination seemed much less involved with their cases than we had experienced with Cardinal. As a psychologist, this significantly impacted my ability to provide the excellent treatment I would have liked to provide. In addition, there were significant delays in service implementation that we had not experienced with Cardinal. Generally, Alliance seemed like a more amateur organization where Cardinal processes seem to be well-oiled.

My brother-in-law lived in a mental health group home in Durham that had existed for 30+ years. Alliance decided that everyone could go live in apartments and closed this group home. We had lots of experience with my brother-in-law trying to live in supervised apartments. This resulted in him debilitating severely and necessitating involvement of the courts to declare him incompetent and at two different times, have a guardian appointed. There was no contact with the family when the decision to close the Durham group home was made. Thankfully, there was an opening at the Nash St mental health group home in Hillsborough run by Cardinal MCO, and that is where he is now living.  As you might imagine, we fear that Alliance would also want to close this group home should they become Orange County's MCO. At the very least, if the transition is made, I would ask that the county make a formal agreement with Alliance to allow this group home to continue operating indefinitely.

I am not in favor of this transition for the above reasons.

Laura Quinn